The Journal of Primary Prevention, VoL 14, No. 3, 1994

Implementing Primary Prevention Programs for Adolescents in Rural Environments Angeline Bushy, PhD, RN 1

Lifestyle behaviors generally are established during adolescence and these habits can increase or decrease a person's chance for a healthful and productive life. Thus, it is important that primary prevention and health promotion begin during those early years. A number of deterrents to the use of health promoting programs are identified but for rural residents there may be other barriers associated with demographic, social, geographic, cultural, economic, educational and political factors. Those environmental factors must be considered when plannin~ implementing and evaluating programs. In turn, provider-community partnerships are an effective strategy to provide services in rural communities within the constraints of limited resources. KEY WORDS: Adolescents; coalition building; rural (at-risk) population.

More than half of the deaths in the US each year result from health damaging lifestyle behaviors. Detrimental habits often are established during adolescence and these may decrease one's potential for healthful and productive living while increasing morbidity and mortality rates. On the contrary, health promotion and disease prevention activities often are initiated during those years as well. Considering the long term effects of these activities, this article focuses on the lifestyle risks and health status of adolescents who live in rural environments. The article concludes with a discussion of provider-community partnerships as a strategy to provide services within the constraints of limited resources (NACHC, 1992; U S D H H S , 1991; USOTA, 1990). First, one must differentiate between health promotion and primary prevention. While the terms often are used interchangeably there are dif1University of Utah, College of Nursing, 25 S. Medical Drive, Salt Lake City, Utah 84112. 209 C, 1994Human SciencesPress, Inc.

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ferences in a person's motivation and goals for each. in essence, health promotion consists of "approach" behaviors to expand the potential for health and well being of individuals, families and communities. Primary prevention, on the other hand, consists of "avoidance" behaviors that help thwart the occurrence of pathogenic insults to health and well-being. These activities are directed toward decreasing the probability of a person, families and communities manifesting specific illnesses or dysfunctions and incorporates active protection against unnecessary stressors. Even though the focus of this Journal is on primary prevention, health promotion is a complementary process. Thus, herein the two terms will be interchanged (USPPSCC, 1992). A number of deterrents to the use of primary prevention programs are cited in the literature and summarized in Fig. 1. For rural residents there may be other barriers associated with demographic, social, geographic, cultural, economic, educational and political factors. Those factors must be considered when planning, implementing and evaluating services in rural communities, particularly primary prevention programs for local adolescents (Frame, 1992; USDHHS, 1986; USOTA, 1990).

RATIONALE The health profile of America's children has shifted markedly in the past 40 years. Once dominated by the threat of major infectious disease Fig. l. Barriers to primary prevention program.

Health System Barriers Inadequate reimbursement to providers Lack of health insurance by patients Mobility of Patients Multiple physicians providing care to a patient (referrals) Sporadic (Categoric) Screening Programs (e.g., health fairs; cholesterol, glaucoma, blood pressure screening clinics) Patient ,Barriers Lack of knowledge about disease prevention and health promotion Lack of confidence in physician's ability to detect "hidden" disease Cost of screening procedures Discomfort Lack of willingness (consciousor unconscious) to change unhealthy lifestyle behaviors Physician Barriers Conflicting standards and recommendations Uncertainty of the value of screening tests Disorganized medical records systems Delayed and indirect gratification from screening activities Lack of time and/or office personnel

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such as polio, diphtheria, scarlet fever, pneumonia, measles, whooping cough; today, widespread immunization has virtually eliminated some of these diseases while others are declining. Current threats to youths' health are associated with low socio-economic status, of which there is a comparatively higher incidence in rural communities. Moreover, physical, emotional and behavioral problems appear to be more prevalent among youth living in poverty than among those in higher socioeconomic levels. Consequently, an accurate profile of the health of adolescents must go beyond mortality and morbidity data. The reports need to consider environmental threats to health and the total cost to those to a community and the nation as a whole. Despite the need for this kind of information, little has been written about certain groups, particularly adolescent living in rural communities. A few citations were published during the mid-to-late 1970s. For the most part, those authors focus on the organization and delivery of perinatal and pediatric health care services rather than primary prevention programs for adolescents (Kirby, 1990). Because of sparse resources, many rural communities do not have primary prevention programs available for their youth. Acknowledging the potential long-term, adverse effects that can result from this short-sighted choice, community leaders and educators are becoming inextricably involved with health professionals to identify ways to distribute existing resources equitably, while providing a continuum of care to residents of all ages (Ahem, 1980; AAP, 1986; Greydanus, 1991; 1992a; 1992b; DeFriese, et al., 1990; Phillips, 1992). In planning and implementing any kind of program, one must be astutely aware that health care in general, and primary prevention in particular, is deeply affected by the cultural beliefs of the community. Families,too, assimilate those beliefs into their lifestyle, including childbearing and childrearing practices. Examples of health related cultural beliefs include one's attitude regarding hygiene, nutrition, exercise, expectation of appropriate and inappropriate behavior of children at various stages of development, decision to seek professional care, manner of interacting when obtaining those services, and degree of compliance with medical advice (Bushy, 1991; Rogers & Burdge, 1986; Taylor, 1992). Utilization reports reveal those who most need preventive services often have the least access to health care for a variety of reasons. Rural, compared with metro residents, also may have a greater distrust of physicians and social service providers, use more self-care and home remedies, and wait longer before visiting a health professional. Consequently, rural people (adults and children alike) are sicker when first visiting a caregiver for an illness. From this one can surmise that, for them, primary prevention probably is not viewed as important. These behaviors often take a "back

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seat" as these are services the family believes they cannot afford. Providers must, therefore, respect a family's beliefs while at the same time educate them on the importance of primary prevention for its members (Human & Wasum, 1991).

CONCEPT OF RURAL AND URBAN What is rural and who do we consider to be a rural resident? The Federal Government refers to metropolitan areas as being over 50,000 and non-metro areas as those having a population under 50,000. Others define rural as having less than 25000 people or living more than 30 minutes from a high density population center (over 50,000). For this submission, urban refers to areas having more than 100 people per square mile; rural having between 6 and 99 people per square mile; and frontier having less than 6 people per square mile. (Rural and frontier are interchanged except when specific reference is made to frontier.) Obviously, not everyone who describes themselves as rural (45% of the total U.S. population) lives on a farm. Less than 5 percent live on farms while the remaining 40% live in small towns throughout the 50 states (Bushy, 1991). There is no 'typical' rural community. Each is unique with its own economic, educational and social structures, as well as its own problems, resources, and patterns of caring for those who are not healthy. Living in small towns or in a sparsely populated area creates some unique experiences for persons, as opposed to counterparts who live in more populated settings, particularly when it comes to accessing primary preventive care. Some of these experiences promote highly positive outcomes but others can have less than desirable consequences for individuals. Subsequent paragraphs highlight commonly encountered rural socio-cultural-economie factors that have been known to impact adolescents' lifestyle and health status (Bergland, 1988).

HEALTH STATUS OF AMERICA'S RURAL YOUTH There are about twenty one million children under age 19 in rural America, representing 33% of the rural population. Yet, useful data on morbidity and mortality in rural regions of the United States is scarce. That which is available suggests that the health issues of urban youth and rural youth are in many ways similar. Across the 50 States, adolescents struggle with teenage pregnancy, sexually transmitted diseases (including transmission of the HIV virus), substance abuse, violence, poverty, family breakups

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(dysfunctionality), limited sexuality education, accidents, and trauma. Likewise, a significant number have chronic illnesses and disabilities that often stem from complications of modern health care (Copan & Racusin, 1983). Thus, attempts to identify significant differences between rural and metro youth often results in striking similarities. Partly, this can be attributed to the fact that all youths are confronted with similar problems evoked by our modern society, and partly because of difficulty in studying this age group. Upon closer scrutiny, however, one finds subtle but significant variations between rural and urban environments can impact adolescents' health status (McManus, Newacheck & Grany, 1990). Poverty Poverty is on the rise in the U.S. Racial, ethnic, and other underrepresented groups have a higher incidence of poverty than Anglo-American counterparts. Constantly we hear of the short and long term consequences for families who live below the established poverty index. Compared to urban communities, rural have a greater poverty rate. Forty percent of all rural families live below the poverty level and one in four rural children are poverty stricken. Minority children, (e.g., Native Americans, Native Alaskans, Native Hawaiians, Blacks, Asians, Mexican-Hispanic Migrant workers, etc.) represent only 20% of the rural population. However, the children in these under represented groups experience even more severe poverty than their Anglo-American counterparts; particularly, substandard housing, poor sanitation, inadequate nutrition, contaminated water, lack of primary preventative services particularly adequate prenatal care, immunizations, health screening and health promoting education and anticipatory counseling. In brief, the poor have more chronic health problems than those having "enough money to live a decent life", and this is especially detrimental to children's health (NIMH, 1986; Stern, 1980). Chronic Illness Regardless where they live, the poor have a higher incidence of chronic illnesses and require more acute illness care. Morbidity reports indicate there are over one million children in rural America with chronic illness and handicaps--75% with significant disability or illness. Yet, per ratio, there are fewer health providers and services available in rural areas. Currently, discussion is underway by policy makers on ways of equitably allocating acute and primary preventive services to people who live in health professional shortage areas (HPSAs). The majority of counties des-

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ignated as HPSAs are located in rural areas of the 50 states (Dunbar, 1992; Williams, 1983). Incidence of Uninsured and Underinsured

Poverty, coupled with depressed economic structures that often exist in small and rural communities, perpetuates the number of uninsured and underinsured families. Of the total U.S. population more than 50% of the medically underinsured live in nonurban areas. This problem is compounded by insufficient numbers of health providers and services, particularly primary preventive programs (Human & Wasum, 1991). Accidents and Trauma

Trauma and violence pose major problems for American youth. The leading cause of adolescent death is car accidents (25,000 per year); thousands are severely injured. In the U.S. there are over 125,000 paraplegics that are trau.ma induced of which a significant number are between ages of 15 to 24. As for rural children, they suffer increased injuries from accidents involving lightening, farm machinery, firearms, drowning and other types of vehicles (boats, snowmobiles, motorcyles, all-terrain vehicles). Yet, pertinent morbidity and mortality data is sparse regarding the incidence and consequences of farm accidents on children. Obviously, this supports the need for primary prevention related to safety for families who live and work in rural environments (Baker, Whitefield, & O'Neill, 1987). Suicide and Homicide

Homicide and suicide are the two leading causes of death for males and the third and fourth causes of death for females from 15 to 19 years of age. Each year between 3-5 thousand youth are murdered and nearly an equal number commit suicide. Comparatively, homicide is more likely to take place in the inner city while suicide is more prevalent in suburban and rural settings. In the past decade there has been a sharp upsurge in the rural suicide rate, especially in male adolescents and young men. In several towns, the rate was of epidemic proportions. A variety of explanations are attributed to those self-inflicted deaths including, increasing economic hardship, changing community social structures, increasing drug and alcohol use, and lack of primary prevention in the form of counseling and other social services (Mason, 1993; USDHHS, 1989).

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Alcohol and Drug Use The National Clearing House for Alcohol and Drug Information (NCHADI, 1991) provides interesting, and somewhat unsettling information about adolescents in rural communities. Their comparison of urban with rural communities from 1984 to 1988 reveals: • Arrests for drug abuse violations increased 54%; • Arrests for use of cocaine and heroin showed an increase of 20%; • The majority of prison inmates in rural states abused alcohol, other drugs, or both; • Children as young as 11 and 12 are drinking as many as 14 to 18 beers on Friday and Saturday night's; • Thirty-three percent of a group of children in a small middle-Atlantic town had their first drink, on their own by the age of 10; • Compared with the national average for similar age groups, Michigan and Wisconsin youth use alcohol at 3 1/2 times that rate; If the above report on the use of alcohol and drugs by rural youth is accurate, the rural homicide probably is comparable to urban counterparts, as well (USGAO, 1990).

RURAL LIFESTYLE What is it like to live in a small and rural town? Even though each is unique, in many ways the experience of living in a small town is similar across the 50 states. The 'typical' rural life-style is characterized by: (Bushy, 1991; Rogers & Burdge, 1986; Murray & Keller, 1991; Stein, 1989). • Greater spatial distances between people and services; • An economic orientation related to the land and nature (agriculture, mining, lumbering, fishing, all of which are classified as highrisk occupations); • Work and recreational activities that are cyclic and seasonal in nature; • Social interactions that facilitate informal, face-to-face' negotiations because most, if not all, residents are either related and/or acquainted. In essence, a small town is the center of trade while its churches and schools usually are the centers for socialization. Those preferences also have implications for planning and implementing primary prevention programs for rural clients.

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Common Themes In Belief System of Rural Groups Belief systems of people are complex and multifaceted. Thus it is impossible to discuss at length the myriad of beliefs of the multiple groups that live in rural environments across the 50 states. A few of the more common themes one hears in the conversations among rural persons relates to their fatalism and subjugation to nature (rain and frost's effects on crop outcome; forest fire's effect on the lumbering industry; hard winter's effect on the livestock industry; hurricane's effect on the fishing industry), and an orientation to concrete places and things. Rural families also tend to be more politically conservative with a strong religious preference ('churchgoing'). In day to day activities, rural persons prefer to deal with people they ~now, rather than a stranger. Access to extended family ("kith and kin") can be advantageous in that participants in the network can be a source of support in a variety of ways, including domestic support and child rearing. Familiarity, however, can create some unusual problems. For instance, because most are acquainted, it can be very difficult for a person to maintain confidentiality and anonymity in a small" town. In turn, breaks in confidentiality can have serious consequences for a person seeking primary preventive care or professional counseling for personal or family concerns. Informal community dynamics pose an even greater concern for highly sensitive adolescents experiencing an emotionally charged concern. They frequently report that there is no one whom they can trust to talk to. Public knowledge about a personal problem can be devastating for a distraught youth, to the point that they believe suicide is the only option for them. Local social and economic structures can impose barriers for adolescents who wish to seek professional help, especially for concerns having moral overtones, such as drug and alcohol dependency, pregnancy, sexuality issues, intense emotional responses to stress or symptoms of mental illness. Self-reliance and Self-care Practices Self-reliance, which includes self-care practices, is a characteristic attributed to rural residents. Historically, self-care helped people to survive in austere, isolated and rugged environments. Self-reliance is reflected in the statement: "We take care of our own"; inferring a preference for receiving care from familiar people. 'Neighborliness' and family support can be beneficial to promote healthy behaviors. At other times, these arrangements facilitate a person becoming enmeshed with others, resulting in unhealthy relationships. A close-knit family can be highly supportive to an

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adolescent having an emotional problem. In other cases, though, family pride can hinder a youth from acknowledging the he or she has a problem. In some situations, the family may actually deter a youth from seeking appropriate counselling or medical care. For instance, emotional problems may be viewed by a family as "a character flaw or family skeleton." Secrecy is reinforced by the rule of silence; that is, what happens in the family m stays in the family. This adage is of particular significance in rural communities where most of the local families have lived and worked together for generations. Thus, in order to save one's integrity in the community, it becomes important not to let everybody in town know about the family's problems, e.g., substance abuse, domestic violence, incest, or emotional disorders. Adhering to established family and community standards can be a source of tremendous stress for adolescents who are struggling to develop their own sense of identity. Work Ethic Reinforced by Economic Structures Economic structures, too, can impact a person's health status as well as his or her health care seeking behaviors. For example, family enterprises are characteristic of rural environments. Small businesses, such as farming, ranching, grocery stores, and service stations generally do not provide employee' benefits, in particular health insurance. Concomitantly, some rural people define health as "the ability to work; to do what needs to be done." This comment reinforces a work ethic and could be interpreted to mean that "illness is not being able to do one's usual work." Economic structures and a work ethic ultimately influence a family's choice of leisure activities, how they view mental health and their choice of health promoting behaviors (Bushy, 1991). Utilization Patterns of Social Support Services Depressed economies have promoted demographic shifts in many small towns. For instance, an "in-migration' of urban residents to rural areas experiencing an "economic boom." In economically depressed communities, there has been an "out-migration" of families to seek employment elsewhere. Both of these situations have produced problems that, in many instances, a small town cannot solve because of the lack of resources. Population shifts disrupt long-established informal "helping networks," creating a need for unusual kinds of human services for localities. Despite the need, primary prevention programs in the form of social and mental health services are unavailable or inaccessible to those target groups.

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Before implementing any primary prevention program, planners must be sensitive to a target groups' preferences of social support. Specifically, three levels of social support are identified in the literature. The first level includes services which are volunteered by family and friends. Generally, there is no remuneration for those actions; but, there is a code of reciprocity between the volunteer and the recipient. The second level includes services that are provided by a group, e.g., civic organization, homemakers club, church circle, fraternity, Chamber of Commerce, 4-H Club, athletic group. The membership provides assistance to needy individuals and families in the community, e.g., volunteering time, food, non-monetary (in-kind) donations, and financial contributions. In turn, the (two) informal levels provide an "insurance policy" of sorts, should a catastrophic event occur for others in the network. The third level of support includes formal (public) services that are sponsored by governmental agencies and private industry, e.g., public health agency, community nursing service, mental health center, school counseling services. Generally, remuneration by clients is expected for those services; albeit, on a fee-based-on-income (NIMH, 1986; Rubin & Rubin, 1986; McManus & Newacheck, 1988), Comparing the utilization patterns of the three levels of support, urban residents prefer the third level. Historically, rural persons relied on the first two levels reinforcing the value of self-reliance. Unfortunately, the recent demographic changes have disrupted natural helping systems in communities that provided informal social support. Those changes forced rural residents to rely more on formal/public support. Unfortunately, the later frequently is provided as a community outreach program by professionals who often are strangers to the community (Rogers & Burdge, 1986).

RURAL HEALTH CARE DELIVERY ISSUES Rural persons preference for informal support, the high incidence of poverty coupled with the lack of available, accessible and acceptable primary prevention programs can be of speciaJ concern for ruralites. The subsequent discussion elaborates on health care delivery issues that impose additional challenges to offering primary prevention to youth living there (USDHHS, 1990; Wakefield, 1990; Wagenfeld & Wagenfeld, 1990). Availability of Services

Availability refers to the existence and the necessary personnel to provide a service. Physicians and nurses in general, primary care providers in

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particular, as well as specialists such as obstetricians, pediatricians, psychiatrists and social service professionals are fewer in rural areas. From an economics point of view, sparseness of population limits the number and array of services in a given region. Feasibly, the per capita cost of providing special services to a few people often becomes prohibitive, particularly in sparsely populated frontier states.

Accessibility of Services Accessibility refers to whether a person has logistical access to, as well as the ability to purchase needed services. Accessibility to primary prevention services by rural families can be impaired by a variety of factors, including; • • • • • • •

great distances that must be traveled to obtain services, lack of public transportation, lack of telephone services, insufficient numbers of providers to offer outreach services, inequitable reimbursement policies, unpredictable weather conditions, and inability to obtain entitlements to obtain services.

Access to funding sources to implement primary prevention programs also can be hampered by the lack of "grantsmanship skills" on the part of those seeking aid. In essence, successful grant writing requires practice, collaborative efforts between agencies, and time to produce a fundable project. Political structures, too, may oppose outside help because community leaders are unable to quantify long-term benefits from primary prevention. For example, resistance may be evidenced by ruralites preference for local government as opposed to "federal and state bureaucracy." Or, it may be demonstrated by formal and informal community leaders not supporting a grant proposal to implement an innovative program to address the primary prevention needs of local adolescents. As for rural power structures, often it is vested in an elite segment of the community. As a group, they often are unaware of the needs of the local underprivileged. Consequently, powerless underrepresented racial and ethnic groups, as well as the children from low income families, experience human service requirements to which the more affluent and powerful majority are not sensitive or sympathetic. Elitist views reinforce the stigma of seeking public assistance, particularly going on welfare or getting counseling from the mental health clinic. Consequently, an adolescent who needs a service mayavoid using it even if it is available and accessible. Their reasoning is that someone in town might

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find out that he or she sought family planning or mental health services. These interrelated delivery issues have serious implications for planning and implementing primary preventive programs. And, in any given situation it is difficult to isolate and correct the deficits that are produced by a single variable. Acceptability of Services

Acceptability refers to whether or not a particular service is offered ha a manner that is congruent with the values of a target population. Considering the wide diversity among rural families, acceptability of available primary prevention services can be hampered by any of the following faciOrs:

Traditions of handling personal problems (self-care practices); Beliefs about the cause of a disorder and the appropriate healer for it; * Lack of knowledge about a physical or an emotional disorder and the place of formal services in preventing and treating the condition; • Difficulty in maintaining confidentiality and anonymity in a setting where most residents are acquainted; and, • The urban orientation of health professionals. A provider's attitude toward rural practice can perpetuate difficulties in relating to the rural environment as well as to the people living there. Coupled with the usual stress that is experienced when seeking preventive care, professional insensitivity can exacerbate an adolescent's mistrust of a professional. Ultimately, their attitude impacts the long-term health status of adolescents who, by nature, often are embarrassed about their health problems, evidenced by minimizing symptoms of illness. Consequently, partnerships between health care providers and a rural community are offered as a strategy to provide primary preventive services that are accessible, available and acceptable to the consumers.

COMMUNITY-PROVIDER PARTNERSHIP MODELS

In light of the foregoing discussion related to the lifestyle risks and health status of adolescents, coupled with long-established belief systems of rural residents and the overriding rural health care delivery issues, providers would do well to work closely with a community when planning

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and implementing a primary prevention program (Mason, 1993). Bear in mind rural residents are known for their resourcefulness. Despite the lack of resources, historically, most fared rather well with self-care, neighborliness and community support. Partnership models are not a new concept to rural communities and three terms have come into vogue to describe them; cooperatives, coalitions and alliances. These models have minor structural variations but a similar overall g o a l - to improve the overall effectiveness of a plan of action to solve a problem through collaboration (Aaronson, 1982; Hardgrove & Howe, 1981; Dickey & Kamerow, 1992; Dunbar, 1992; Hibbard, Nutting, & Grady, 1991; Tierney & Baisden, 1990). Collaboration is derived from a Latin word meaning to work together. Partnership models are composed of two or more organizations working together on an issue or project which here-to-fore would have been undertaken by a single person/group. For instance, a partnership in a medically underserved rural community that focuses on providing primary preventive care to adolescents might be made more effective by: • Combining resources and working together to recruit health professionals; • Hiring and sharing the expertise of a school nurse or school counselor; • Conducting a multi-county adolescent health needs assessments to determine the area's predominate health concerns; • Planning among local agencies to avoid duplicating services, augmenting existing services and reducing professional and agency turf issues. In many cases, long standing problems can be resolved by the combined efforts of several interested organizations in a small community. Since schools often are a central meeting place for small-town residents, the educational system may be in an ideal position to facilitate collaborative discussion among concerned parents, teachers, health care professionals, civic organizations, and industry. With effective facilitation, informal discussions among concerned residents can evolve into a more formal provider-community partnership such as a cooperative, coalition, alliance.

Cooperatives Cooperatives are informal partnerships formed by a group of persons becoming aware of another organization that is interested in the same concern. Often, these arrangements are initiated through informal discussions among interested community members, which leads to a formal meeting

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between other interested groups. Or, individuals may simply express willingness to work together on some aspect of an activity. Cooperatives, albeit informal in nature, are more effective to plan and implement primary prevention programs, than if several individuals worked independently on that project. Yet, none of the participants in the cooperative must compromise their autonomy. Obviously, some communication and consultation is necessary for cooperatives to use resources more effectively and reduce duplication of services. Coalitions

Coalitions are a loosely organized structure in which several groups agree to address a particular problem. For instance, a county-wide coalition focusing on adolescent primary prevention care might include representatives from social service agencies, schools, mental health clinics, school athletic clubs, 4-H Clubs, church and civic groups. This coalition will provide leadership in assessing the community's predominant adolescent health concerns, prioritizing the identified needs, developing a strategic plan of action, and implementing the plan for an integrated primary prevention program. Alliances

Alliances are formal, long range partnerships having a formal administrative structure and requiring membership dues. Consider the previous example of the multi-county partnership having as its priority addressing the health care needs of adolescents. In this case, an alliance would be comprised of a number of public and private institutions as well as civic and service groups that are willing and able to pay a membership fee. Presumably, each participating group also will have representation on the board of directors and voting power. Activities the alliance might foster, include • Implementing a primary prevention program in mental health for adolescents in the area; • Provide community education programs for youth group leaders, teachers and parents on child developmental theory; • Arrange a workshop for teachers, religious leaders, athletic coaches, and leaders of youth groups on effective communication techniques and crises intervention. This information should enable them to intervene more effectively when encountering an adolescent with a problem;

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* Implement a multi-county-wide drug and alcohol awareness program; o Initiate a local crisis intervention team to provide consultation and support to faculty, parents, students and others in the community following a serious accident, suicide(s), or homicide(s) of a local youth; o Develop a community-wide protocol to address issues of confidentiality if (when) a local youth tests positive for the HIV virus. Whatever the model, the members share the goal of providing a continuum of care for local adolescents ranging from health promotion and primary prevention, to include emergency and acute care services, as well as tertiary care. Bear in mind, though, that a rural partnership may be different in nature than one in a more populated community.

ESTABLISHING COMMUNITY PARTNERSHIPS Stemming from churches and schools central importance in a rural community, leaders from those two institutions often become key figures in organizing provider-community partnerships. This is a new experience for many. Hence the question arises, where do we start and how do we proceed? In response to their request, Figures 2 and 3 outline the goals, objectives and activities to establish a partnership. The remaining paragraphs summarize the process outlined on the figures (Dunbar, 1992; Fuszard, et al., 1991; Hubbard, et al., 1991; Pommerenke & Dietrich 1992a; 1992b; NIMH, 1986; Rubin & Rubin, 1986).

Figure 2. Building Provider-Community Partnerships In building a partnership, the organizational phase precedes all others. This phase lays the foundation for all other activities related to planning and implementing primary prevention programs for adolescents. The goals of this phase are: 1. Gain active and passive support from the community; 2. Persuade Certain community groups and individuals to form and participate in an organization representing the community-atlarge; 3. Enlist this representative group to accept the responsibility for developing a satisfactory solution to the health care problem.

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The following figures represent the relationship of the goals objectives and activities in building provider-community partnership models.

GOAL #1 To Gain Active And Passive Support From The Community

T

Objectives L Establish a basic organiza- 2. Assess and document the tional structure so that sub- existence of the health sequent activities can be problem. carried out efficiently.

T I. Designate or elect certain members as officers with specific responsibilities. 2. Establish a meeting schedule: send advance mailings of meeting notices; make reminder phone calls. 3. Follow a prepared agenda for each meeting to keep discussion focused. 4. Assign various responsibilities to group members to promote continued interest and involvement. 5. Record minutes of meetings to keep track of progress and decisions, and to follow up on assigned responsibilities. 6. Communicate your activities and progress to the community.

Activities 1. Gather and document additional case histories. 2. Seek information about difficulties in obtaining care by contacting local health care providers. 3. Ask local hospital(s) for information on the extent to which patients are using the emergency room for non-emergency care. 4. Contact nearby communities to learn if similar problems are being experienced and whether any effort is being made to solve them. 5. Seek information and/or confirmation from the local health planning agency. 6. Seek assistance from the regional health planning agency. 7. Seek assistance from the local, regional or state department. 8. Do household/telephone survey.

3. Increase community awareness of the problem's significance.

T 1. Identify and contact influential and affected citizens in your community. 2. Request organization and agency members contacted to brief their respective groups on your efforts and plans; offering backup assistance and resources from your group as needed. 3. Have group members serve as speakers to local civic organizations, clubs, etc. 4. Ask these community groups to appoint a representative to serve as a member of your group. 5. Find out if there are other people in your community or nearby communities involved in similar activities and plans. 6. Establish contact with the local press briefing them on your concerns and activities. 7. Hold a community-wide meeting open to the public and the press.

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Figure 3.

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Building Provider-CommunityPartnerships GOAL #2

AND 3

To Persuade Certain Community Groups And Individuals To Form And Participate In An Organization Representing The Community To Enlist This Representative Group To Accept The Responsibility For Developing A Satisfactory Solution To The Health Care Problem

T Objectives 1. Consolidate accumulated 2. Have the newly created Representative Group support and convert this support into a Representaformally constituted and duly appointed by a well tive Group with members who have indicated a willrecognized community body, ingness to commit time and energy to resolve the problem.

1 1 Identify individuals among your active supporters who are willing to become working members of the group. 2. Request influential organizations or agencies from all segments of the community to appoint someone to serve on the representative group. 3. Seek individual members representing any major portions of the community as yet unrepresented. 4. Formalize the organizational framework by electing officers and restating the group's long-range goals.

l

3. Educate Representative Group members.

Activities

I. Identify those community groups that are most influential in the communit), and would serve as appropriate sponsor~ 2. Determine which of these appropriate groups am most supportive of your colgerns arid efforts. 3. Select one among them and request formal apix)intment. Invite this appointing p u p to include one of its members in the RG. 4. Seek advice from the appointing group as to whether there are any key people missing from the RG. 5. Clarify mutual responsibilities of the appointing group and the RG. 6. If your first choice has not been willing, seek appointment from a 2nd or 3rd choice. 7. If a formal appointment from one group does not teem possible, proceed on your own with informal support from many groups; try to obtain letters of support from a variety of sources.

T

1. Confer with citizem of your community, 2. Confer with health care providers in your cornmunity, including program administrators, 3. Confer with health care providers in other communities, including program administrators, 4. Collect published informatinn available through local, state, and federal agencies, 5. Solicit information and assistance from the local or areawisl¢ health planning agency,

4. Have the Representative Group accept responsibility for maintaining contact and dialogue with the total community.

T I. Develop a mailing list and agenci~ (including press) to be regularly notified of your activities. 2. Issue regular press releases covering the group's objectives and progrese. 3. Contact various agencies and key individual* on a regular basis to keep them abreast of the group's activities. 4. Plan occasional open meetings to keep the community aware of your activities and your group aware of community opinion. 5. Encourage group members to serve as program speakers at meetings of various agencies and organizations.

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Step One: Identify the Problem Area After a community problem is identified, recruit a team of 2 to 5 members who have a common interest in addressing the concern, in this case making primary preventive care accessible to adolescents in under served rural communities. Through dialogue, an informal group often becomes aware of others in a community having similar interests; hopefully, leading to an organized partnership, e.g., cooperative, coalition, alliance.

Step Two: Assess the Community's Perspective Before developing a plan of action for a particular problem, it is wise to complete a community assessment. This data is useful to: * e • • •

gain the local perspective, assess the degree of public awareness and support for the cause, identify special-interest groups, identify existing services to avoid duplication of programs, and list potential barriers and resources in the community.

Data can be obtained by written or telephone surveys, personal interviews, the media, as well as public health reports. Always include the views of community leaders, representatives from local organizations as well as the "man-and-woman-on-the-street." In this instance, involve adolescents as their ideas are critical in planning an effective and acceptable course of action for their health concerns.

Step Three: Analyze the Data Once the assessment is completed, the data must be analyzed to include identifying and prioritizing the issues of concern. For instance, when planning a meaningful primary prevention program, compare and contrast the lisfed concerns with available providers and existing services in the community.

Step Four:. Develop a Long Range Plan After completing the data analysis, one can begin long range planning. For a program to be effective and accepted by the target group(s) involve as many organizations and individuals as feasible or interested. A

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multi-county partnership focusing on primary preventive care for adolescents might focus on the following activities: • Preparing a list of possible target groups or clients; • Generating a list of potential community volunteers and professionals who can assist with the project; • Purchasing necessary materials to implement the program; • Creating awareness among target groups of a particular program, e.g., individuals, families, schools, youth, church and recreation groups, health care professionals, law enforcement personnel and other religious, service and civic clubs. • Identifying potential funding sources to implement the program.

Step Five: Take Action Once a course of action is developed and there is group consensus implement the plan. Remember, the best laid plans can go awry especially when working with several individuals and groups. When planning and implementing a primary prevention program, flexibility is critical in order to change the process as the situation requires to provide services that are accessible, available and acceptable by the target group.

Step Six: Program Evaluation As the program is developed and during its implementation, plan for on-going (formative) evaluation of the process as well as a final (summative) evaluation. Together, the two methods are useful to measure the short-term and long-term outcome(s) of the program and if the problem has been adequately addressed. For instance, with primary prevention a short term outcome might be per capita utilization of services within a specified time frame. Long term outcomes, however, may not be obvious for a decade or more as with interventions to reduce the number of teenage pregnancies, domestic violence and substance abuse.

CONCLUSION Caught up by societal and environmental changes, adolescents engage in experimentation and develop lifestyle behaviors that may become permanent. For instance, behaviors related to diet, physical activity, tobacco, alcohol and drug use, personal safety, and sexual behavior. Through pri-

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mary prevention there has been some improvement in the last decade in the health status of America's youth. Many are still confronted by a constellation of problems stemming from environmental factors that can impact their health status. In the case of adolescents living in rural environments, provider-community partnerships have been found to be an effective strategy to implement a continuum of available, accessible and acceptable health care services within the constraints of sparse resources.

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